Has Iran achieved the goal of reducing the prevalence of households faced with catastrophic health expenditure to 1%?: A national survey

Abstract Background and Aims One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5‐year development plan (2016−2021). This study was conducted to evaluate the level of access to this goal in the final year of this program. Methods A national cross‐sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis. Results 8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p < 0.05). Conclusion In the final year of the sixth 5‐year development plan, Iran has not yet achieved its goal of “reducing the percentage of households exposed to CHE to 1%.” Policymakers should pay attention to factors increasing the odds of facing CHE in designing interventions.


| INTRODUCTION
According to the World Health Organization, one of the ultimate goals of health systems is to financially protect citizens against the catastrophic health expenditure. 1 Households will face catastrophic health expanditure (CHE) when they spend more than 40% of their payment capacity out of pocket for receiving health services. 2,3 Health systems try to reduce the share of out-ofpocket payments (OOPs) when using health services by implementing mechanisms such as prepayments, subsidies, and free essential health services to increase financial protection.
According to the World Health Organization, the CHE index in countries should be less than 1%. 4,5 Annually, a significant percentage of the world's population, often living in low and middle-income countries, face catastrophic and impoverishing health expenditures due to the direct payment of health costs, or avoid receiving appropriate and timely health services. [6][7][8] OOP of health expenditures is the most unfair way of financing health systems and brings about the highest risk for households to face CHE. 9,10 However, the main method of financing health systems in low and middle-income countries is OOP. 11 Universal health coverage and financial protection of citizens against catastrophic health expenditures is one of the obligations of many countries in the world including Islamic Republic of Iran. 12 For this purpose, in Iran, in the law of the fourth (2005−2009), fifth (2011−2015), and sixth (2017−2021) 5-year development plans, as one of the national strategic plans and upstream documents of the country, reducing the prevalence of Iranian households facing CHE to 1% has been set as one of the significant goals in these plans. 13 In this regard, measures and policies such as increasing the percentage of population with basic health insurance, implementing rural family physician program and the health system transformation plan (as the latest reform in the country's health system whose details are given elsewhere) have been implemented so far. 12,14 However, at the end of the fourth and fifth development plans, this goal was not achieved and according to various national studies, there was a significant difference between the current situation and the predetermined goal (1%). [15][16][17] According to the report of the research center of the Iranian parliament, the value of the CHE index for the country was reported 6% at the end of 2016 (final year of the fifth development plan). 18 Therefore, the goal of reducing the percentage of households facing catastrophic health expenditures to less than 1% was again included in the agenda of the Iranian parliament and in the sixth development plan (Article 78). 13 According to the studies conducted during the years of this program implementation, reaching this goal has not yet happened.
Periodic measurement and regular monitoring of this index and its feedback to the policymakers of the health system is necessary to know the value of this index and implement the necessary reforms.
We are now at the end of the sixth development plan and the present study aimed to evaluate the prevalence index of Iranian households facing CHE.

| Study design
This national cross-sectional study was performed on Iranian households in 2021.

| Data collection tools
World Health Survey Questionnaire developed by the World Health Organization was used to collect the data. 19 This questionnaire has been translated in Iran and its validity and reliability have been confirmed in previous studies. 7 This questionnaire was completed through an interview with the head of the household or an informed household member over 18 years of age. The questionnaire consists of three parts: 1. Background characteristics, demographic and socioeconomic status of the household.
2. Status of using outpatient health services (including visiting a doctor, psychologist, midwife and nurse as well as using medication and laboratory services), dental and rehabilitation services and hospitalization. The recall period for using outpatient, dental and rehabilitation services was 1 month (last 30 days) and the recall period for using inpatient services was 1 year (last 12 months).
3. Monthly household expenses by type of expense, including total household expenses, household food expenses and OOPs for health services. In this study, the recall period for total household expenses was 1 month (last 30 days).

| Sampling and sample size
The sample size was estimated to be 385 households based on the following formula; taking into account the exposure of 50% of households to CHE (p = 0.5), 95% statistical significance, and 5% accuracy rate. Due to the fact that the study was conducted in 5 provinces, the total sample size was determined to be 2000 households (400 households from each province).
Multi-stage sampling was used to choose the samples. The country was divided into 5 geographical regions and one province was selected from each region. Five selected provinces included Tehran, Kurdistan, Golestan, Hormozgan, Kohgiluyeh and Boyer-Ahmad. In the next stage, within each province, the capital city (county) of the province was selected. Then, within each county, the center and its villages were selected. Next, 10 centers were randomly selected from the comprehensive health centers in each city and 10 centers from rural health centers. Finally, from the list of households

| DISCUSSION
Universal health coverage means that everyone has access to health services they need without facing financial barriers. 23  the percentage of households exposed to CHE to 1%, but also, compared to the findings of previous studies, this gap seems to have become deeper. 15 pandemic has affected the CHE index in various ways, such as increasing health costs, increasing unemployment, weakening the household's economic status, and reducing the household's ability to pay. [24][25][26] In addition, in recent years, Iran has had a growing inflation, which can also be a reason for that. [27][28][29] According to the findings of another systematic and metaanalysis study in Iran (2017), the prevalence of households faced with CHE was reported to be 3.9% (95% CI, 3.26−11.07). 30 Also, in the latest systematic and meta-analysis study in Iran (2018), in total, the percentage of households exposed to CHE was 7.5% (95% CI, 6.2−9.1) and for inpatient services was 35.9% (95% CI, 23.5−54.3). 15 Also, according to the report of the research center of the Iranian parliament, the value of the CHE index for the country at the end of 2016 (end of the fifth development plan) was reported 6%. 18  In most similar studies conducted in Iran, these variables have been reported as variables affecting the CHE. 7,31,32 In Iran, despite the fact that a high percentage of population is covered by basic health insurance (nearly 90%), service coverage and depth of coverage of health costs are not in a good situation and these insurance companies have not been able to provide adequate financial protection of people against health costs and a significant part of the costs is paid out of patients' pockets. 33 In Iran, dental and rehabilitation services and equipment are not covered by basic health insurance and most of these services are also provided by the private sector that it leads to an increase in household health costs and subsequently increases the risk of CHE. In most studies, the use of rehabilitation and dental services have been reported as determinants of exposure to CHE. 7 The results of a systematic and metaanalysis study in Iran (2021) showed that health insurance companies do not provide effective financial protection against CHE. 33

ACKNOWLEDGMENTS
We would like to thank those who participated in the study. This study was funded by Kurdistan University of Medical Sciences with contract number 1399.076. However, there was no role of the funding body in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author (Bakhtiar Piroozi) upon reasonable request.

ETHICS STATEMENT
This study was approved by ethics committee of Kurdistan University of Medical Sciences with the code IR.MUK.REC.1399.076. Participation in the study was voluntary and written consent was obtained from the participants.

TRANSPARENCY STATEMENT
The lead author Bakhtiar Piroozi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.